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Clinical Depression Versus Distress Among Patients With Type 2 Diabetes

Not just a question of semantics

¹ Department of Family and Community Medicine, University of California, San Francisco, California
² Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California
³ Department of Psychiatry, University of California, San Francisco, California
⁴ Department of Medicine, University of California, San Francisco, California
⁵ Kaiser Permanente of Colorado, Denver, Colorado

Address correspondence and reprint requests to Lawrence Fisher, PhD, Department of Family and Community Medicine, Box 0900, University of California San Francisco, San Francisco, CA 94143. E-mail: fisherl{at}fcm.ucsf.edu

OBJECTIVE—We sought to determine differences between structured interviews, symptom questionnaires, and distress measures for assessment of depression in patients with diabetes.

RESEARCH DESIGN AND METHODS—We assessed 506 diabetic patients for major depressive disorder (MDD) by a structured interview (Composite International Diagnostic Interview [CIDI]), a questionnaire for depressive symptoms (Center for Epidemiological Studies Depression Scale [CESD]), and on the Diabetes Distress Scale. Demographic characteristics, two biological variables (A1C and non-HDL cholesterol), and four behavioral management measures (kilocalories, calories of saturated fat, number of fruit and vegetable servings, and minutes of physical activity) were assessed. Comparisons were made between those with and without depression on the CIDI and the CESD.

RESULTS—Findings showed that 22% of patients reached CESD 16, and 9.9% met a CIDI diagnosis of MDD. Of those above CESD cut points, 70% were not clinically depressed, and 34% of those who were clinically depressed did not reach CESD scores 16. Those scoring 16, compared with those <16 on the CESD, had higher A1C, kilocalories, and calories of saturated fat and lower physical activity. No differences were found using the CIDI. Diabetes distress was minimally related to MDD but substantively linked to CESD scores and to outcomes.

CONCLUSIONS—Most patients with diabetes and high levels of depressive symptoms are not clinically depressed. The CESD may be more reflective of general emotional and diabetes-specific distress than clinical depression. Most treatment of distress, however, is based on the depression literature, which suggests the need to consider different interventions for distressed but not clinically depressed diabetic patients.

Abbreviations: CESD, Center for Epidemiological Studies Depression Scale • CIDI, Composite International Diagnostic Interview • DDS, Diabetes Distress Scale • DSM-IV, Diagnostic and Statistical Manual of Psychiatric Disorders, 4th edition • IPAQ, International Physical Activity Questionnaire • MDD, major depressive disorder

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